Inferior Vena Cava Thrombosis Inferior Vena Cava Thrombosis ABSTRACT Thrombosis of the inferior vena

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  • J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 7 , 2 0 1 6

    ª 2 0 1 6 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N I S S N 1 9 3 6 - 8 7 9 8 / $ 3 6 . 0 0

    P U B L I S H E D B Y E L S E V I E R h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j c i n . 2 0 1 5 . 1 2 . 2 6 8

    STATE-OF-THE-ART REVIEW

    Inferior Vena Cava Thrombosis

    Mohamad Alkhouli, MD,a Mohammad Morad, MD,b Craig R. Narins, MD,a,c Farhan Raza, MD,d

    Riyaz Bashir, MBBSd

    JACC: CARDIOVASCULAR INTERVENTIONS CME

    This article has been selected as this issue’s CME activity, available online

    at http://www.acc.org/jacc-journals-cme by selecting the CME tab on the

    top navigation bar.

    Accreditation and Designation Statement

    The American College of Cardiology Foundation (ACCF) is accredited by

    the Accreditation Council for Continuing Medical Education (ACCME) to

    provide continuing medical education for physicians.

    The ACCF designates this Journal-based CME activity for a maximum

    of 1 AMA PRA Category 1 Credit(s)�. Physicians should only claim credit

    commensurate with the extent of their participation in the activity.

    Method of Participation and Receipt of CME Certificate

    To obtain credit for this CME activity, you must:

    1. Be an ACC member or JACC: Cardiovascular Interventions subscriber.

    2. Carefully read the CME-designated article available online and in this

    issue of the journal.

    3. Answer the post-test questions. At least 2 out of the 3 questions

    provided must be answered correctly to obtain CME credit.

    4. Complete a brief evaluation.

    From the aDivision of Cardiovascular Disease, University of Rochester Med

    Medicine, Temple University Hospital, Philadelphia, Pennsylvania; cDepart

    versity of Rochester Medical Center, Rochester, New York; and the dDivi

    Hospital, Philadelphia, Pennsylvania. The authors have reported that they h

    paper to disclose.

    Manuscript received September 8, 2015; revised manuscript received Novem

    5. Claim your CME credit and receive your certificate electronically by

    following the instructions given at the conclusion of the activity.

    CME Objective for This Article: 1) Identify the clinical context in which

    inferior vena cava thrombosis should be suspected. 2) Describe the

    diagnostic tests for inferior vena cava thrombosis. 3) Differentiate the

    various treatment modalities of inferior vena cava thrombosis with

    respect to the indications, risks versus benefits, technical aspects and

    patient selection.

    CME Editor Disclosure: JACC: Cardiovascular Interventions CME Editor

    Bill Gogas, MD, PhD, has received research grant support from NIH T32,

    Gilead Sciences, and Medtronic Inc.

    Author Disclosures: The authors have reported that they have no re-

    lationships relevant to the contents of this paper to disclose.

    Medium of Participation: Print (article only); online (article and quiz).

    CME Term of Approval

    Issue Date: April 11, 2016

    Expiration Date: April 10, 2017

    ical Center, Rochester, New York; bDepartment of

    ment of Surgery, Section of Vascular Surgery, Uni-

    sion of Cardiovascular Disease, Temple University

    ave no relationships relevant to the contents of this

    ber 22, 2015, accepted December 17, 2015.

    http://www.acc.org/jacc-journals-cme http://crossmark.crossref.org/dialog/?doi=10.1016/j.jcin.2015.12.268&domain=pdf http://dx.doi.org/10.1016/j.jcin.2015.12.268

  • Alkhouli et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 7 , 2 0 1 6

    IVC Thrombosis A P R I L 1 1 , 2 0 1 6 : 6 2 9 – 4 3 630

    Inferior Vena Cava Thromb

    osis

    ABSTRACT

    Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and

    long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the

    presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United

    States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for

    developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis

    and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition

    by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in

    patients with IVC thrombosis. (J Am Coll Cardiol Intv 2016;9:629–43) © 2016 by the American College of Cardiology

    Foundation.

    I nferior vena cava (IVC) thrombosis is anunder-recognized entity that is associated withsignificant morbidity and mortality (1). It is esti- mated that 2.6% to 4.0% of patients with lower ex- tremity deep vein thrombosis (DVT) have IVC thrombosis (2–5). However, the true incidence of IVC thrombosis may be underestimated due to the lack of standardized methods of its detection and reporting, as well as the exponential increase in the number of unretrieved IVC filters in the United States, a major predisposing factor to IVC thrombosis (5,6). The mortality rate of IVC thrombosis is twice as high as that of DVT confined to the lower extremities (2). If untreated, patients with IVC thrombosis will also suffer from significant morbidities: post- thrombotic syndrome (PTS) in up to 90%, disabling venous claudication in 45%, pulmonary embolism (PE) in 30%, and venous ulceration in 15% (1,3,4). Phlegmasia cerulea dolens and renal vein thrombosis are rare, but well-described, limb and life-threatening complications of IVC thrombosis (7).

    In this review, we aim to enhance the awareness of this uncommon, but morbid, condition, and pro- vide readers with a guide detailing the diagnosis and management of IVC thrombosis with special emphasis on contemporary endovascular treatment modalities.

    ETIOLOGY

    CONGENITALLY ABNORMAL IVC. IVC thrombosis is prevalent (60% to 80%) among patients with congenital IVC anomalies (8–10). These anomalies occur in 0.5% to 1% of the general population, and in 2% to 3% of patients with congenital cardiac defects (9,11). Congenital IVC anomalies can be classified into 3 anatomic categories (12) (Figure 1):

    1. Infrarenal: duplicate IVC, persistent left-sided IVC, pre-aortic IVC, and absence of the infrarenal IVC

    2. Renal: accessory left renal vein, retroaortic and circumaortic left renal vein

    3. Suprarenal: absence of the hepatic IVC with azygos continuation, congenital caval stenosis or atresia, and IVC membranes

    Most IVC anomalies are subclinical for many years due to well-developed collaterals. They are often discovered incidentally on abdominal imaging (10). However, thrombosis of the collateral channels or of their feeding vessel (often the common iliac vein) can lead to acute or subacute proximal DVT or findings of chronic venous insufficiency.

    CONGENITALLY NORMAL IVC. Thrombosis of the IVC in the absence of congenital abnormalities is rare, and is usually a result of a predisposing hy- percoagulable state along with an acquired pathology in the IVC or one of its adjacent structures (1,7,13,14).

    1. Prothrombotic factors: thrombophilia, malignancy, oral contraceptives, smoking, obesity, pregnancy, hormonal replacement therapy, and nephrotic syndrome.

    2. Abdominal pathology: renal cell tumor, abdominal masses producing extrinsic compression such as a very large uterine fibroid, Budd-Chiari syndrome, abdominal trauma/surgery, May-Thurner syn- drome, and thrombotic occlusion of an IVC filter.

    Thrombotic occlusion of IVC filters is of particular importance in the United States, where presumed overutilization of IVC filters and low retrieval rates have drawn recent attention. It is estimated that IVC filter placement rates in the United States in 2012 were 25 times that of an equivalent population in Europe (224,700 vs. 9,070) (6). Although the majority

  • AB BR E V I A T I O N S

    AND ACRONYM S

    ACCP = American College of

    Chest Physicians

    CDT = catheter-directed

    thrombolysis

    CT = computed tomography

    DVT = deep vein thrombosis

    GCS = graduated compression

    stockings

    IVC = inferior vena cava

    MR = magnetic resonance

    J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 7 , 2 0 1 6 Alkhouli et al. A P R I L 1 1 , 2 0 1 6 : 6 2 9 – 4 3 IVC Thrombosis

    631

    of implanted filters are retrievable in design and placed in patients without clinical indications for permanent caval interruption, the highest retrieval rate reported in the United States is only 34%, and some series have reported retrieval rates of

  • FIGURE 1 Graphic Illustration of the Most Common IVC Congenital Anomalies

    IVC ¼ inferior vena cava; L ¼ left; R ¼ right. Adapted with permission from Truty et al. Congenital Anomalies of the Inferior Vena Cava and Left Renal Vein: Implications During Open Abdominal Aortic Aneurysm Reconstruction. Ann Vasc Surg 2007;21(2):186-97.

    Alkhouli et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 7 , 2 0 1 6

    IVC Thrombosis A P R I L 1 1 , 2 0 1 6 : 6 2 9 – 4 3 632

    considered in symptomatic patients. However, the overall management in not likely to change as anti- coagulatio